Losing Patience

Despite $104 million in federal funds, VCU's indigent health care program leaves some patients in a lurch. Critics say it's all part of the plan.

Janet Armstead considers every trip to the doctor's office a blessing. But the road she takes sometimes seems more painful than the cure.

Suffering chronic effects of a past bout with Lyme disease, the usually boisterous woman with short-cropped hair and dark, expressive eyes arrived for her Feb. 2 doctor's appointment wracked by crippling pain.

“My hip was killing me,” says Armstead, an animated and vivacious woman whose constant motion belies the pain she suffers. “The doctor sent me for X-rays. And he wanted me to go to an orthopedic clinic too.”

It's a routine referral to a specialist that most patients with health insurance take for granted: Within a week or two, most people can get an appointment with the primary care physician and then with a specialist. It's the sort of trip that's supposed to be routine for Armstead too, despite her meager means, lack of insurance or money to cover the bill. That's because she has basic health benefits under Virginia Commonwealth University Health System's indigent patient program, Virginia Coordinated Care for the Uninsured, known by the initials VCC.

Instead, Armstead says, “it took [VCC] two weeks to even make the appointment,” which then was scheduled another week or more out without consulting her on the date. When she finally was back at her primary care doctor for the follow-up to that initial Feb. 2 appointment, it was March 16 — more than a month without relief from the pain. And still no date with a specialist.

“The worst part is in between that time the doctor's office called me to tell me they'd made an appointment to the orthopedic clinic,” she says, laughing at how expediently she'd be seen for the second referral: “July 10. I'll be either dead or crazy by then.”

Even getting approval to go crazy or die may get an indefinite extension because of bureaucratic red tape: Armstead's orthopedic appointment is two months after her membership in the coordinated care program expires.

“They want you to forget it,” Armstead says of the equally complicated two-month renewal process to remain in the program. “And then when you go to the doctor's and you realize you don't have [coverage], it's embarrassing.”

Armstead counts herself fortunate to have some kind of health care coverage, but her months-long trips to the doctor are becoming increasingly commonplace. She isn't the only one.

The bureaucratic red tape that mars VCU Health System's indigent program has come under fire of late. Physicians and hospitals that participate in the program and a vocal interfaith advocacy group say the program's inefficiency has a crippling effect on the uninsured.

For the city's poorest residents, the university's coordinated care program is supposed to bridge a growing gap in health care. It offers indigent patients perhaps their only option when it comes to preventative care — covering regular doctor's visits to catch ailments early, especially for aging patients. Without it, often the only option is a trip to the emergency room.

VCU has acknowledged there are problems and inefficiencies and promises to retool its broader indigent care program, which brings more than $104 million in federal funding to the university every year.

But there are larger forces at work, critics say. The complaints about the program are varied and range from inefficiency and towering bureaucracy — like what Armstead faced — to suggestions by some critics in the medical community that VCU intentionally holds back on the larger pot of federal money that could be doing much more good in the community.

Federal regulations require the $104 million of federal money be spent within VCU's walls, but some doctors suspect that VCU has intentionally hedged on applying for a federal spending waiver that would allow the school to spread some of its wealth out into the community. It would allow hospitals and doctors not directly part of the university to create an indigent care safety net that would mean better care for more patients at a decreased cost, they say, but would also mean a smaller piece of the funding pie for VCU.

“I think for any program there are always areas for improvement,” says Sheryl Garland, vice president for community outreach at VCU Health System, who defends the university's record with the indigent care program and the federal money it protects. “One of the things we are working on is identifying those [improvement] areas with our community partners and with our patients.”

VCU Health System sees more than 40,000 indigent patents every year — people from all over the greater Richmond area and from all walks of life. Few of them are indigent in the common sense of the word. Most are working poor, like Armstead, with jobs that provide minimum-wage pay. They work hard but they struggle to stay afloat.

The indigent care program that covers Armstead serves about half of the 40,000 indigents, those meeting specific federal eligibility guidelines. The program was developed about nine years ago as an alternative to caring for the region's growing indigent population. In essence, it established a health-care safety net of community doctors. They'd see patients who in the past relied almost exclusively on expensive hospital emergency room visits for conditions as varied as from routine medical checkups to life-threatening injuries.

The yearly cost of this highly effective — if sometimes frustrating — program is paid separately out of the $104 million in federal funds. VCU directly foots its comparatively meager $4 million price tag, with the basic premise being that by spending that money the university can distribute the $104 million in federal dollars to improve care for all indigent patients across a broader spectrum.

In essence, an ounce of prevention is worth a pound of cure. Patients develop healthy relationships with family doctors, and by seeing them regularly catch serious maladies early when they're less costly to treat.

In many respects, the strategy is working. Emergency room visits at the university for nonemergency care are down among patients enrolled in the indigent care program, according to Garland, even while they're up overall among all other indigent patients.

In spite of the improvements VCU says it's made, community doctors who participate in the coordinated care program think more could be done with $104 million.

“As we talk about reforming our [national] health care system, as people begin to lose their jobs and lose their health benefits, they have to have somewhere to go,” says Dr. Lerla Joseph, owner and president of Charles City Medical Group on Hull Street.

“Treating those patients in a private-practice, primary-care setting, hospitalizing them when they need to and getting diagnostic tests that they need to have done,” she says — “If we were able to do that for 20,000 patients on [$4 million] then the expenditure and the use of the funds could be much better managed.”

Despite the evidence that increased care by primary care physicians saves money and improves patient outcomes, the health system nearly shut down much of the program just a few weeks ago.

On March 4, university officials, including Garland and Sheldon Retchen, chief executive of VCU Health System, met with the program's community doctors to inform them that the hospital would see as many as half of their patients directly. The $5 monthly maintenance fees on remaining patients might also be reduced, doctors were told. Bon Secours Richmond Community Hospital, a major treater of overflow program and other indigent patients, also was to be cut out of the program.

Major pushback from doctors caused the university to rescind the planned changes.

But it's a shame the hospital had to be reminded of that fact, Dr. Joseph says.

“I see the program being improved as a result of having this recent controversy developing,” says Joseph, though she remains disappointed that the university hasn't yet seen the importance of keeping Community Hospital also in the VCC program. The hospital remains scheduled to lose its VCC contract May 16, Garland confirms.

Joseph says this decision remains one without any evident logical purpose.

“I asked about [Richmond Community Hospital's] cost per hospital stay versus a stay at VCU, and [VCU] acknowledged the cost was much lower at Richmond Community,” she says. “It seemed to me the … decision was not a proper decision based on the cost savings they had realized.”

More importantly, there could be a genuinely devastating impact on patients, says another doctor familiar with the Richmond Community Hospital negotiations.

“Imagine a situation where you're in VCC and you call an ambulance for chest pain and you say go to VCU but the ambulance driver says VCU is [full], so they take you to Richmond Community,” the doctor says. “Think about this person that's now going to get strapped with this sort of medical bill. … all because [VCU] doesn't have a contract and she gets diverted to a hospital that's not in the program.”

The Community Hospital situation and its potential impact has blipped on the radar of city government. Mayor Dwight Jones met with VCC representatives March 26.

“It's presently a situation that we're just monitoring,” says Tammy Hawley, the mayor's spokeswoman. “There's no position or comment for us to make on the matter at this time. Of course the mayor is concerned about the quality of care for all citizens.”

Meanwhile, another group continues its two-year campaign for improvements to the coordinated-care program, seeking more effective use of that $104 million. Richmonders Involved to Strengthen our Communities, or RISC, an interfaith advocacy organization drawing its strength from dozens of area religious congregations in the greater Richmond area, plans to call university leaders on the carpet at a massive rally April 20.

At a smaller rally last month, the advocacy group laid out its concerns both in strident biblical metaphor and well-researched statistics. The Rev. Tyrone Nelson, pastor of the historic black congregation at Sixth Mt. Zion Church in Jackson Ward, is not an animated preacher — his delivery is quiet, intense and earnest. But his words are full of fire.

“Systemic evils take years and years and years to become entrenched — our challenge is to hold those systems accountable,” Nelson told a recent gathering of supporters. “It is our job every day that the church is alive to make sure we speak against … things that are not of the common good. We won't be quiet until we see tax dollars spent in the correct way.”

Some see progress on the horizon. Pastor Ralph Hodge of Second Baptist Church on South Side is hopeful, yet guarded.

“It looks like they might be trying,” says Hodge, who will have met with university officials twice in recent weeks, and who is sorely disappointed with VCU's inaction since the group first approached officials a year ago. “They didn't change a thing — nothing changed last year. I think they thought we were going to go away.”

The request Hodge, Nelson and RISC make is simple on its face: Find a way to use more of the $104 million toward preventative care, and the basic cost of indigent care will decrease, allowing more indigent patients to get better treatment.

At a bare minimum, Hodge says, his group wonders why the university doesn't work to promote the program among indigent patents.

“Why not promote it like Bon Secours is promoting [primary care]?” Hodge asks. Though Bon Secours specifically targets indigents, its recent marketing campaign has focused on the importance of a medical home for patients, with a regular physician who knows your troubles. “VCU needs to take the lead in providing medical care — as someone receiving federal and state dollars,” Hodge says.

Instead, the university uses its $104 million to spend about $500 per month, per patient, says Hodge — far in excess of what it might cost simply to provide each of those 40,000 patients with a basic HMO-style plan. A recent VCU presentation confirms this: “per member, per month costs [were] $511 in 2006 for Virginia Coordinated Care for the uninsured program.”

“You could almost sign them up for Trigon or Cigna and get them insurance,” Hodge says. In a meeting with the university's Retchen in April 2008, Hodge says the university told the advocacy group that it wasn't financially feasible to promote the program to such a degree and still afford the basic care currently being provided.

Hodge is unconvinced. A similar program that serves a much larger population did exactly that. Virginia's Family Access to Medical Insurance Security program, known as FAMIS, cost the state and federal government about $169 million in 2007 to provide full insurance coverage for almost 82,500 children. When compared with the university's $104 million for 40,000 patients who mostly receive occasional services, Hodge believes the differences are stark. “When they wanted to get all the kids on the FAMIS program,” he says, “that was everywhere — key chains, billboards, you couldn't get away from it.”

Preventative care makes sense, he says, as the Bon Secours campaign would indicate, as a proven cost-saving approach to any community health initiative.

“If [medical leaders] are saying it's best practice for the paying customers, why is it not best practice for the people the government is paying for?” Hodge asks. “We're not backing down from that.”

Advocates may not plan to back down, but little has occurred since last April when they first approached the university. University officials promised to conduct a survey of patients to determine more effective means of providing services. To date, the survey remains in the initial planning stages, VCU's Garland says, with a small pilot study completed this past February.

It's even more staggering how little was done since a group of participating VCC doctors first asked university officials about applying for that federal waiver to allow the $104 million to be spent more creatively.

In early 2005, according to doctors participating in the coordinated-care program, they first broached the possibility of applying for the federal spending waiver. Notes from a March 2005 meeting of the VCC steering committee show that the topic came up. Also discussed was an earlier proposal suggesting a waiver application just for Richmond Community Hospital.

In 2005, VCU's Garland told the community doctors that there was progress on the waiver applications. Some attendees at the 2005 meeting say they'd been previously led to believe that the waiver application had been submitted as early as 2004. They asked Terone Green, then a member of the state Medicaid board, whether any such application had been submitted.

“The community physicians had been told that the waiver existed [and] had been submitted,” Green says. “Several doctors asked me to look into that waiver. … The information that I got was quite different from what was shared with them.”

In fact, he says, he found that no waiver had been submitted.

Garland says there was a misunderstanding.

“I am sorry that's the way the minutes are reading,” she says. “There was not a waiver submitted in 2004.”

As for submitting a waiver request in 2005, she says, VCU sought advice, but submitted no waiver application: “We had submitted a request to [Centers for Medicare and Medicaid Services] to ask if we could share the DSH dollars.”

There has been recent progress, Garland says.

“We are working on the waiver now,” she says, calling it a touchy process that's fraught with pitfalls. “There is a format that is critical to follow. We have been working to be sure that we have covered all of the bases that we have to cover.”

Garland says the university has watched as the federal government has approved waivers in other states only to have those state's programs “unable to meet the criteria” and face “having some of their [funds] removed.”

Why it's taken six years to prepare a waiver application remains unanswered.

“We do plan to apply for the waiver, that has been our intention,” Garland says. “Our goal is to have this waiver submitted as soon as we complete all our documentation.”

Her best guess is another six months, “and that is my goal — to get it out as soon as possible. … We have a lot of data to collect.”

In the meantime, patients like Armstead continue to share stories of bureaucratic red tape and delayed treatment.

After a meeting two weeks ago with community doctors and ministers, Armstead says, a woman came up to her with a story like no other she's heard.

“She had tears in her eyes,” Armstead says, as the woman recounted the story of her uncle. “He was waiting to be financially screened. He was waiting to get the [membership] card so he could go to the doctor. It took too long. His leg was bad anyway, she said, but when he got to the doctor, all they could do was amputate.

“People are trying to get the help,” she says. “It shouldn't be that hard.”

“Most of our experience has been positive,” Prizzio says. “The program has limitations clearly. … Our [low-income] population in particular has a hard time navigating through systems. Someone who finds this very alien, they find it so confusing that they keep bumping into walls.”

But once in, Prizzio says, patients get the care they need. He acknowledges delays for specialty care when his doctors refer patients to VCU, “[But] I'm not sure three to six months is accurate [for VCU referrals].”

One simple issue, he says, is that there just aren't enough specialists to go around. “If you wanted to get in to see a dermatologist right now, it would be two months, [whether a patient] has health care or not. There's just not enough specialty care providers.”

But with a patient with critical need, there's still little excuse for such delays, Prizzio says. “If somebody has a tumor that you suspect to be malignant … no, it's not optimal to have it wait three or four weeks.”

And it does happen. One area VCC participating doctor who asked not to be identified for fear of jeopardizing his other associations with the university, says he's had a very recent experience where getting specialty care for a patient has been a less than expedient process.

“I needed a cardiac test and they gave me an appointment for September,” he says. He acknowledges that he can't know that the patient is critical, but “it could be a triple bypass. My [medical opinion] is they need the test.”

Garland defends VCU's process, explaining that booking patients is done in an insurance neutral way. In other words, patients are not evaluated on their form of payment or insurance when appointments are made.

“We make every effort,” she says.

Keshia Barnett suspects not. A lupus sufferer enrolled in the indigent care program from 2001 to October 2008 — she now has a job with private health insurance benefits — she found the program to be inefficient and difficult to navigate.

“I could never get into the rheumatology clinic — I was only in there probably about two or three times [in seven years],” Barnett says, also complaining of appointments two or three months after her doctor's referral. “The times that I really needed to go or felt like I needed to go, I couldn't get in. That was really frustrating.”

It's no surprise to Dr. Joseph Boatwright, the former medical director of VCC.

He's seen the good and the bad in the program, and he remains both a staunch supporter and an unwavering critic. Boatwright sees the program as an essential part of the health care safety net in Richmond. He says it gives coverage to those people who fall through the cracks, those who can't afford private insurance and don't qualify for other public programs.

“Look at those patients that are living paycheck to paycheck,” he says. “Look at how many people that affects — 80 percent of VCC patients have at least a part-time job. They are not street people or drug addicts like someone might think.”

In fact, he says, they're likely to be a neighbor or a co-worker.

“That's the kind of brag for the program — how it's supposed to work,” Boatwright says, of VCC's importance in closing the gap in heath care. “That's why I got involved in the program. I could see patients that were just on that edge like that — they were one appendectomy away, or it could just be a fall off a step ladder.

“That's the kind of thing this program is there for,” he says, “if it's done right.” S

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